Early changes in consciousness after severe brain injury: diagnostic accuracy and patient characteristics

BACKGROUND: An accurate classification of the level of consciousness is essential across all phases of treatment in patients with severe brain injury, as it directly informs therapeutic decisions and prognostic evaluations. However, differentiating disorders of consciousness (DoC) in clinical practice is challenging and associated with a high risk of misdiagnosis, particularly when based on a single assessment. AIM: This study evaluated the diagnostic accuracy of a single Coma Recovery Scale-Revised (CRS-R) assessment, misdiagnosis rates, and the clinical profile of patients with DoC during early rehabilitation. METHODS: In this observational study, 213 patients with severe acquired brain injury were consecutively enrolled. The level of consciousness was assessed with the CRS-R at weeks 2, 4, 8, and 12, and at discharge. For patients initially diagnosed with unresponsive wakefulness syndrome (UWS), a standardized protocol comprising three CRS-R assessments over two consecutive days was implemented. RESULTS: At week 2, 61 patients were classified as UWS on the initial CRS-R assessment. Of these, five (8.2%) were reclassified as MCS based on signs of consciousness observed during the second or third CRS-R assessment, and two additional patients (3.3%) were reclassified as MCS based on interdisciplinary clinical consensus despite being classified as UWS in all three CRS-R assessments. Thus, the final diagnostic classification comprised 54 patients (25.4%) with UWS, 92 (43.2%) with MCS, and 67 (31.5%) with non-DoC. CONCLUSIONS: Given the challenges of detecting signs of consciousness, repeated CRS-R assessments combined with an interdisciplinary consensus-based diagnostic approach provide a feasible strategy to improve diagnostic accuracy in routine care.